Obsessive Compulsive Disorder, Substance Abuse, and Recovery

The Features of OCD

Obsessions: Theseconsist of intrusive and repetitive images, thoughts, or urges that lead to stress or anxiety. The individual attempts to suppress these images, urges, or thoughts by using some action.

Compulsions: These are defined as behaviors or mental acts that are repeated as a result of the obsession. Repeating the behavior or thought reduces the anxiety that is associated with the obsession.

For one to actually have OCD, the above behaviors must be time-consuming. According to the American Psychiatric Association, they must consume more than one hour per day as well as cause significant stress or impairment to one’s everyday activities.

A number of different specifying conditions for OCD can be present. For example, some individuals may recognize that their repetitive thoughts and behaviors are irrational, whereas others may believe them to be perfectly valid and see no need to change.

It is also important to note that there is a personality disorder that is described as obsessive-compulsive personality disorder. This is quite different from the clinical disorder described above and represents a longstanding pattern of behaviors related to being obsessed with control, rigid, and fixated on the organization of minor details as opposed to experiencing the obsessions and compulsions described above.

Most often, the rumination subtype is reserved for those who experience intrusive thoughts of a magical, religious, violent, or other nature.

One of the most common examples of OCD is the contamination type of OCD. The obsession regarding cleanliness, and recurrent thoughts related to being dirty or contaminated by germs or other substances, drive the compulsion for individuals to repeatedly wash their hands, clean themselves, and avoid any form of dirt real or imagined (such as avoiding public restrooms). This pattern of intrusive and recurring thoughts (obsessions) and repetitive behaviors to deal with the anxiety these thoughts produce (compulsion) leads to a number of issues with the individual’s ability to function in a normal manner.

According to the American Psychiatric Association, the prevalence of OCD appears to be around 1-1.5 percent with female adults affected at a slightly higher rate than male adults; although in children, this pattern appears to be reversed. There are some genetic influences that appear to be associated with some people who have OCD; however, there is no definitive cause identified for OCD.

OCD is often comorbid with several other psychological disorders. For instance, OCD appears to occur fairly frequently with ADHD, depression, other anxiety disorders, bipolar disorder, and certain personality disorders. The comorbidity of OCD and substance use disorders may vary significantly, depending on whether or not OCD and a substance use disorder are the primary disorders identified or whether the person is diagnosed with another psychological disorder. Of course, any individual who has OCD, another psychological disorder such as bipolar disorder, and substance abuse issues would require a multidimensional and team approach to treatment.

Nonetheless, it appears that OCD does share a significant comorbidity with substance abuse. For instance, a 2009 study reported in the Journal of Anxiety Disorders looked at a sample of 323 individuals with OCD as their primary psychological disorder and found that 27 percent of that group had a substance abuse issue over their lifetime, with a substantial majority reporting that their substance abuse occurred after their OCD symptoms appeared. Similar findings are reported in a study conducted in Great Britain. It appears that alcohol abuse is particularly prevalent in individuals with OCD; however, other drugs of abuse are also of concern.

There are two interesting features of these studies. First, the lifetime prevalence of a disorder refers to the finding that individuals have the disorder at some time during their lives; however, the disorder may not be actively present when the individuals or participants in the study are actively engaging in study. While the finding that individuals with OCD have relatively high rates of substance abuse over their lifetimes, both studies also noted that during their participation in the studies, the percentage of individuals currently reporting substance abuse was far less (around 5 -10 percent). Thus, it appears that individuals with OCD either address their substance abuse issues on their own or deal with their substance abuse issues over time. Neither study reported how their participants addressed their substance abuse issues.

The second interesting feature is that it appears that in the majority of cases, the substance abuse issue followed the appearance of OCD in the participants in the studies. There is other research to suggest that many individuals (but not all of them) who suffer from similar disorders, such as anxiety disorders, may often turn to substance abuse to deal with the anxiety and distress produced by the disorder. This suggests that if OCD can be treated early, a subsequent substance abuse issue may be avoided (at least in the majority of cases).

The type of CBT that is tailor-made for individuals who have any subtype of OCD is known as exposure and response prevention therapy. This treatment has been shown to have high rates of success with OCD. Individuals confront their anxiety directly, but under conditions where they can control the anxiety. Individuals experience the results of not completing the obsessive behavior.

This can be done as the individual is using a relaxation technique or by using varying degrees of intensity, such as starting with conditions that arouse only mild anxiety and working up to conditions that invoke extreme anxiety. As the individual is exposed to these situations, anxiety will peak and then dissipate, and the person will learn that there is little to actually fear.

An approach using CBT to treat the obsessions and compulsions of OCD might concentrate on:

Identifying the individual’s obsessions (for example, “I have to be in a sterile environment,” or “Having any amount of dirt on my hands is intolerable.”)

Applying behavioral techniques, such as getting the individual to learn relaxation and stress reduction techniques

Having the individual actually face anxieties and confront them while practicing stress reduction and relaxation (or starting with situations where anxiety is relatively mild and building up to more intense situations; for example, actually having an individual get dirty during a therapy session and maintaining a state of relaxation while not allowing the person clean up)

Over time, these types of strategies and exposure techniques are associated with a reduction in anxiety, and the individual the longer needs to engage in obsessive-compulsive cycles of behavior. The ultimate goal is to eliminate the anxiety associated with irrational beliefs and the need to engage in the compulsive behavior.

Moreover, brain imaging research has indicated that the pattern of activation observed in the brains of individuals with active OCD actually changes to a more normalized state as a result of these forms of CBT. Likewise, CBT is also suited to deal with substance abuse issues in the same manner, by identifying irrational thoughts and beliefs associated with substance abuse and changing these to effect change in behavior.

If an individual is suffering from both OCD and a substance use disorder, the therapy can be applied to address both issues at the same time. Typically, it is preferential to treat co-occurring disorders together, and OCD rarely occurs in isolation. The substance abuse component would be treated in a similar manner where the individual’s irrational beliefs about how substance abuse aids the person are challenged and then more proactive attitudes and beliefs are tested. Individuals can also benefit from involvement in support groups such as 12-Step groups.

Other options for the treatment of OCD include antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. In some cases, anti-anxiety medications can reduce anxiety; however, these anxiolytic or anti-anxiety medications have a potential for addiction and need to be used under strict supervision of a psychiatrist. Medications approved by the Federal Drug Administration for the treatment of OCD include:

Anafranil (tricyclic antidepressant)

Luvox (SSRI)

Paxil (SSRI)

Prozac (SSRI)

Zoloft (SSRI)

Using medications, such as antidepressants and anti-anxiety medications, can aid progress in CBT sessions. The use of medications alone to treat either OCD or substance abuse does not result in the development of long-term coping strategies and behavioral change. Thus, if medication is used, it should be used in conjunction with therapy. The medication can complement the therapy, but it not a substitute for learning how to deal with the obsessions and compulsions of OCD.

There is a subset of individuals with very severe OCD that do not respond to therapy or medication. Deep brain stimulation and psychosurgery have been used in these cases, but typically, they are not used until other options are ruled out.

Of course, this entire process is complicated by the presence of other psychiatric disorders and substance abuse issues. In complicated cases, a multidimensional approach with a team of therapists, psychiatrists, and other medical professionals may be needed.

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